As primary care facilities, labor and delivery units, and rural health clinics close, more and more birthing people are at risk of adverse maternal health outcomes, especially in rural areas. Often, these closures are due to high operational costs, low Medicaid reimbursement rates, and staffing shortages. March of Dimes reported that five percent of U.S. counties have less maternity access in 2022, compared to just two years ago. These low and limited access areas affect up to 6.9 million women and almost 500,000 births in the U.S. People living in rural areas are also more likely to experience lower prenatal care initiation, higher rates of hospitalization, low birth weight, and more pre-term births. Finding an Obstetrics and Gynecology physician (OB-GYN) within a reasonable distance can also be challenging.
As a result, many rural patients have become increasingly reliant on family medicine providers for maternal and obstetric health services. While residency programs often lack comprehensive financial and educational support, developing more opportunities for family medicine providers to train in maternal health and obstetrics may address some of these issues.
This increased reliance on family medicine practices has affected clinics across the U.S., as these physicians are often culturally and geographically situated to provide critical maternal health services. A survey of 216 rural hospitals across ten states found that family practice physicians delivered babies in 67% of rural hospitals between 2013 and 2017. In about 27% of rural hospitals, the family medicine physicians were also the only ones who delivered babies. Arguably, the most surprising discovery was that if the family physicians had not been available, most patients would have had to drive an average of 86 miles round-trip for maternal health care.
Despite these providers being responsible for much of the rural maternal health care, few family medicine doctors choose to practice in rural areas. There has also been a national decline in obstetrics training in family medicine practices. For example, in 2021, only about 15% of providers practiced obstetrics, compared to about 43% in the 1980s. This decrease could be due to a combination of low reimbursement rates, increasing medical liability costs, and a demanding amount of “on-call” time.
With limited educational, professional, and financial incentives, this has left many rural birthing people at risk of losing essential obstetrics-related care; however, investing in family medicine maternal and obstetric training may be a viable and innovative solution.
The American Academy of Family Physicians (AAFP) voiced the importance of implementing educational strategies to promote family physician obstetrical services. Family medicine residency programs vary in obstetrical training requirements, available opportunities, and ways to meet accreditation requirements. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) transitioned obstetrical training from a volume-based to a competency-based model that requires 200 hours through a 2-month rotation. A study conducted among family medicine program directors around the change indicated that most family medicine residents graduated with reduced delivery experience, and residency programs are placing less priority on continuity deliveries.
But as of July 2023, residents are required to have at least 100 hours (or one month) dedicated to the care of patients with gynecologic issues, including obstetric and gynecologic care, family planning, contraception, and other educational reproductive health topics.
To truly effect change in family medicine maternal health competency, residency programs must offer more hands-on learning opportunities in diverse settings. State and local preceptorship programs, such as the Texas Family Medicine Preceptorship Program, have successfully influenced medical students to choose primary care. With proper funding and support, these programs may allow medical students to explore and ultimately pursue a family medicine role.
Federal agencies are also starting to focus on the importance of family medicine obstetrics training. In July 2023, the Department of Health and Human Services (HHS) invested $11 million in new rural programs that include obstetrical training. Then, in August 2023, the Health Resources & Services Administration (HRSA) announced a three-year grant to the University of Rochester Medical Center to support family medicine resident training in a rural setting and increase access to family medicine and obstetrics for historically marginalized and low-income residents in New York. Through this grant, a consortium of hospitals will implement the Rural Track Program (RTP) with a Maternal Health and Obstetrics Pathway (MHOP). Through the training, physicians will be proficient in the full spectrum of family medicine and able to independently manage prenatal, postpartum, and delivery-related care in rural areas. Starting in June 2026, the residency program will increase from 12 to 14 residents per year, totaling 42 residents.
Mississippi also proposed the first fellowship to train up to three family physicians yearly in obstetrics to increase rural and underserved areas with additional prenatal, delivery, and postpartum care. Mississippi had a record-breaking number of family medicine physicians in 2023, but the University of Mississippi Medical Center OB-GYN residency averages only five or six graduates yearly. Of those who graduate, only about two residents practice in Mississippi despite the state’s worsening maternal health crisis, lack of a certified midwife program, and high medical liability premiums. The proposed fellowship will have physicians rotate between medical centers every three months, hoping to provide opportunities to study obstetrics and gynecological surgeries. This program is intended to shift the family medicine obstetrics landscape to increase in-state provider retention and reduce health disparities in maternal health deserts.
These efforts, among others, may better equip family medicine practitioners with the necessary training, experience, and expertise to deliver comprehensive care in rural areas, hopefully resulting in better maternal health outcomes and greater accessibility.
